A Few Patients on Friday, June 23

Apologies in advance to all of you for the medical jargon. This is just a tiny picture of the kind of patients who arrive at our clinic on foot or by picki-picki, and very occasionally by larger vehicle. While I was struggling with translations and trying to understand the history of these few patients, and looking things up on the computer, and examining these folks, the nurses remaining in clinic (just two, the other two being out on projects of outreach and education,) saw and treated dozens more, while also translating for me and helping me find equipment, and making decisions on what medications to give since they know the formulary.

The 22 year-old woman who arrived at 7 or 8 last night with sudden onset delirium has become less confused and is no longer combative, which she was intermittently last night. Last night her heart rate was 120 at times and she was not talking, and intermittently had some automaticity to her movements: chewing and smacking her lips. HIV and Malaria both negative on the Rapid Diagnostic Tests (RDTs). This morning, after intramuscular diazepam (Valium) last night, all vital signs are stable. She is initially texting to her husband, and within an hour or two she is talking. Stool test is positive for Giardia lamblia, a common protozoa. I believe she should be referred for an EEG, at least, and some blood tests we can’t do here, like a complete blood count, basic chemistries, thyroid, vitamin B12 and folate levels. However, she is discharged home with metronidazole for the Giardia. The staff theorize that she has hysteria or domestic problems (they cannot get more specific as to what those might be).

A possibly 57 year-old woman (she cannot tell us a birth date or age—just said she didn’t know) who fell while walking and struck her left cheek, requiring stitches, returned for a wound check and dressing change today. She is doing well and did not suffer much pain while she slept. She smelled of alcohol last night, (very rare in this practice) but not this morning. I actually changed the dressing, which feels like real work for a change, and I asked her to come again in two more days to check the wound.

Female infant of 2.8 months whose mother died during childbirth* and is being cared for by the grandmother, with the presenting complaint of cough and hotness of the body for two weeks. (Hotness of the body is a typical complaint, and is abbreviated in the medical record as HOB.) The child completed a course of amoxicillin with no improvement. She is underweight (-2, just above the cut-off for referral to nutrition services) and under-height (-3—referral for investigation of the malnutrition is recommended) with a papular rash around the neck, but more worrisome is the thick-sounding cough and the grunting respirations. The grandmother was feeding formula for a while, but it was too expensive so she is feeding cow’s milk only. We settle on erythromycin orally, to treat some bacteria that Amoxacillin doesn’t cover. We add salbuterol as a bronchodilator, and zinc oxide for the rash around the neck. I hope that she will come back with some improvement in breathing, and can gain weight if not so sick. There do not seem to be any nutritional services to recommend, and we have no formula or other supplement for her.

12 year-old boy with an itchy rash, fine papules coalescing into patches with a sand-papery surface, for two weeks. Only when he takes his shirt off do we see a lump about 2 inches in diameter on the left thorax, which is draining pus and blood. He says that has also been present for two weeks. With minimal pressure, about a ml of pus and blood is expressed. He has no fever but the insides of his eyelids look pale. We try to find a cause for the possible anemia so check the stool for ova and cysts of worms, but the test is negative. The packed cell volume, which is 34%, seems like mild anemia to me, but the lab technician thinks that is well within the range for an African male. He says they usually range from 28-42%, but not the 45% that I am more familiar with, perhaps due to less iron and protein in the diet. The abscess is drained in the treatment room, and he is sent home on both an antibiotic and an oral anti-fungal. He will come back if he needs to, but no follow-up appointment is arranged.

Note that fully half of these patients are completely outside of my specialty of internal medicine, which bills itself as “Doctors for Adults.” I am very challenged to see pediatric, maternity, and emergency-room patients, but the nurses take care of everyone and stay calm doing it! We refer only an occasional patient out for an x-ray or for care at another level, like the young man I saw with severe acute renal failure, and another high-school student with a (probable) psoas abscess caused by tuberculosis.

*Every day in 2015, about 830 women died due to complications of pregnancy and child birth. Almost all of these deaths occurred in low-resource settings, and most could have been prevented. The primary causes of death are haemorrhage, hypertension, infections, and indirect causes, mostly due to interaction between pre-existing medical conditions and pregnancy. Of the 830 daily maternal deaths, 550 occurred in sub-Saharan Africa and 180 in Southern Asia, compared to 5 in developed countries. The risk of a woman in a developing country dying from a maternal-related cause during her lifetime is about 33 times higher compared to a woman living in a developed country. Maternal mortality is a health indicator that shows very wide gaps between rich and poor, urban and rural areas, both between countries and within them. (WHO.)